Clinical Audit Lead

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

Best People, Best Solutions, Best Results

Job Summary:

Owns responsibility for ensuring the optimal performance of the medical review division, continuously monitoring and analyzing performance metrics to identify opportunities for improving processes and procedures. Assists and supports Director - Medical Operations in operations and administration of contracts, overseeing the day-to-day activities of clinical teams. Communicates regularly and serves as a liaison with government agencies, regulatory bodies, and other external stakeholders to ensure transparent and compliant company programs. This position will serve as the Provision of Services Element Lead on audits of Program of All-Inclusive Care for the Elderly (PACE) Organizations. On each audit, the clinical audit lead will have responsibility for:

• Reviewing universes and sample selection.
• Conducting and documenting medical record reviews in audit working papers.
• Overseeing/reviewing the medical record reviews of up to four clinicians on the audit team.
• Communicating with PACE organizations, including document requests and debriefs.
• Writing formal audit findings in line with CMS audit report writing guidelines.
• Reviewing corrective action plans provided by PACE organizations in response to audit findings.
• Identifying and recommending process improvements and constructive feedback for future protocol considerations.

Essential Duties and Responsibilities:

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  Supervises a group of clinicians on audit to monitor and determine PACE organizations' compliance with relevant laws, regulations, and organizational policies.
  
  
  
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  Ensures clinicians' audit documentation is accurate, complete and in line with CMS's guidelines. Provides technical guidance to team members if errors identified.
  
  
  
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  Reviews medical records through remote access to a PACE organization's electronic medical record (EMR) or PDF within a narrow fieldwork timeframe.
  
  
  
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  Collaborates with internal subject matter experts and peers to share lessons learned or identify trends that may be of interest to CMS.
  
  
  
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  Collaborates with CMS and external stakeholders (such as the state-administering agency) on all matters related to assigned PACE audits.
  
  
  
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  Works closely with the PACE SME and Program Director to manage workload, ensuring timeliness and quality of work products.
  
  
  
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  Provides feedback to PACE SME and Program Director regarding audit team members' performance informally and through the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.
  
  
  
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  Provides job-specific orientation and training as requested.
  
  
  

To perform the job successfully, an individual should demonstrate the following competencies:

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  Business Expertise- Good understanding of how the team integrates with others in accomplishing the objectives of the department.
  
  
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  Problem Solving- Uses judgment based on practice and precedence.
  
  
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  Nature of Impact- Direct impact by ensuring the quality of the tasks/services/information provided by self and others.
  
  
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  Area of Impact- Primarily on closely related work teams.
  
  
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  Interpersonal Skills- Developed communication skills to exchange complex information.
  
  
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  Leadership- Allocates work as a team leader; may check on completion/quality.
  
  
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  Functional Knowledge- Good understanding of PACE regulations and operations. Ability to apply established audit methodologies.
  
  
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  Project Management- Provision of Services Element Lead checking the work of others. Typically responsible for training and developing new team members.
  
  
• Technological- Use of EMR and CMS systems necessary; may assist team members in troubleshooting EMR remote access for audit).

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.